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Defense Friendly Opinion for Residential Treatment – D. Utah

12-06-2018, 11:10 AM

Here’s a new case out of the District of Utah titled Joel S. et al., v. Cigna et al. In this matter, the plaintiffs are pursuing residential care treatment for their minor child. The court first finds:

But the S Family has provided no evidence that the Cigna or MCMC reviewers ignored the treating physicians’ letters other than that Cigna’s denials did not directly address the letters. It is true that Cigna did not refer to these letters directly, but a failure to mention them does not per se indicate a failure to consider them. And this court cannot require the administrator to disclose what weight it gave the treating physicians’ letter because the Supreme Court has concluded that courts may not “impose on administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician’s evaluation.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 824 (2003). Further, even though the treating physicians’ appeals on behalf of S.S. are compelling, courts have concluded that treating physicians are not in the best position to evaluate a patient because of the sympathy a treating physician may feel for his or her patient. See Black & Decker, 538 U.S. at 832; Williams v. Metro. Life Ins. Co., 459 F. App’x 719, 726 (10th Cir. 2010) (unpublished). Therefore, Cigna’s failure to discuss the treating physicians’ letters does not make the denial arbitrary and capricious. Because Cigna’s denial of the S Family’s claim for benefits for S.S.’s treatment at Menninger from October 11 on is based on substantial evidence, the court will not disrupt Cigna’s decision.

The court concludes:

Not satisfied with this outcome, the S Family again sought IRO review, and its claim was again assigned to MCMC. MCMC’s anonymous board-certified reviewer provided a “Clinical summary” and extensive review of the records that referenced eighteen different psychiatric sources in reaching its conclusion. (Id. at 278–84.) After noting the S Family’s concern with S.S.’s “dual diagnosis issues” and a review of the “[p]rogram notes,” the reviewer stated that the treatment S.S. was receiving at Solstice was not medically necessary because it was not “in accordance with generally accepted standards of medical or dental practice” and was not “clinically appropriate” because a less restrictive environment was available. (Id. at 279–82.) The reviewer also noted that S.S.’s diagnosis included “chronic self loathing/self injury,” which “is largely an outpatient treatment condition utilizing individual and group therapy for dialectical behavioral therapy along with medication management.” (Id. at 282.) The reviewer further noted that there were community options for drug and family related needs. (Id.) The reviewer then cited eighteen sources related to childhood trauma, residential treatment for adolescents with mental illness, substance abuse treatment, childhood anxiety disorders, and adolescent depression. (Id. at 282–84.) The reviewer’s conclusion reflects her review of the program notes and was supported by many studies. Thus, the reviewer reached a reasoned conclusion based on substantial evidence, so the decision was not arbitrary and capricious.

The S Family’s primary remaining arguments that Cigna improperly concluded residential treatment was not medically necessary are that Cigna had previously recommended residential treatment and that its reviewers failed to apply medical necessity criteria for drug abuse. (Motion 38, ECF No. 27.) But Cigna did not represent that residential treatment was medically necessary in its denial of coverage for Menninger. Dr. Shampaine’s notes, which Dr. Blank also referenced, reflect that at the time of the interview with Dr. Robert-Ibarra, discharge to therapeutic boarding school was the contemplated next step. But those notes are dated October 13, 2013, approximately three weeks before S.S. left Menninger. (Sealed Record 215–16.) As such, they have little bearing on what was medically necessary in the first week of November. And no Cigna denial letter stated residential treatment was appropriate. They state only that S.S. could be treated at a lower level of care. The S Family’s dual diagnosis argument is similarly misguided. Each reviewing physician referenced Solstice’s conclusion that she dealt with alcohol and drug abuse and documented her consumption and goals. And as Cigna points out, coverage upon admission to residential treatment for substance abuse under the Guidelines is only available if the patient has a “documented diagnosis of a moderate-to-severe substance use disorder.” (Response 35, ECF No. 30; Sealed Record 121.) These arguments do not change the fact that the record includes evidence supporting the conclusion that S.S. could have been treated at a less restrictive level of care, making residential treatment not medically necessary.